Saturday, October 24, 2015

CURE magazine, launched in 2002 for cancer patients, survivors and caregivers, has become the largest consumer magazine in the United States focused entirely on cancer. With a circulation of 300,000 individual subscribers account for over 170,000 of that figure with the remainder going to cancer centers and advocacy groups around the country. Since its inception, CURE has expanded to reflect the entire cancer continuum, including supportive care issues and long-term and late effects.

Cancer' is a terrifying word. The first time I heard the word directed at me was in 1996. I was 32 years old. I had just had a colposcopy after an irregular pap smear. The call from my gynecologist was forwarded to me at the library reference desk where I was working.

"The pathology report showed cancerous cells. We need to remove them. I'd like to do a LEEP procedure so we can get clean margins."

It was stage I cervical cancer. I was at work. I will never forget that feeling of shocked confusion as I finished my shift.

The phone would continue to be a part of my cancer journey.

In 2011, there was a suspicious mammogram, followed by a biopsy. I was informed by phone that the biopsy showed cancer. After the next test, an MRI, I was told by phone that the scan showed two distinct tumors in my breast. I was also told by phone that the HER2-positive breast cancer had spread to my bone and liver. This call was made by my oncologist's nurse practitioner as I was sitting down in the chair to receive my first chemo. The bone and CT scans had just been returned to my oncologist, and they were trying to stop the previously planned chemo so that we could change treatment direction in light of the new diagnosis. The nurse practitioner pronounced that the scans showed lesions on my bones and spots on my liver. In my mind, spots on the liver meant I was going to die and die soon. I had taken the call at the nurse's station. When I heard the nurse's words, I began to sob and I began to hate the phone.

But as time went on, and I received more test results, I realized I didn't hate the phone. I hated the way in which news was being delivered over the phone. The radiologist who called to confirm that the breast biopsy showed cancer was kind, measured and detailed in her report. I was grateful for this approach, even calmed. My gynecologist who called to tell me that the breast MRI showed two tumors had not even bothered to have the scan report in her hand during the call and was dismissive of my questions. The nurse practitioner who informed me of my stage 4 metastatic breast cancer turned out to be someone who lacked social skills and should not have been informing patients of any test results. It's all in how the informing is handled.

In cancer, as in other areas of medicine, early detection can save lives. But the screening tests used to find early tumors also detect disease that would never cause problems — disease you'll die with but not from. Managing those cases means giving potentially harmful treatment to patients who won't benefit.

DCIS, or ductal carcinoma in situ, is the poster child of this dilemma. Before routine mammograms, only about 1 percent of U.S. breast cancer cases were DCIS. Now nearly 65,000 women a year — about 22 percent of those with breast cancer — are diagnosed with DCIS.

DCIS, also known as Stage 0 breast cancer, is not life-threatening, and not all cases will progress to invasive cancer. But because there is no reliable way to determine which ones will, nearly all DCIS is surgically removed with a lumpectomy or mastectomy (and sometimes the healthy breast is removed prophylactically). Most DCIS patients also are offered radiation and drugs.

While many experts believe this simply is the price that must be paid to save lives, an increasingly vocal minority are working to find ways to reduce overdiagnosis and overtreatment, especially of DCIS.

These researchers got a big boost in August from a new study of more than 100,000 women diagnosed with DCIS between 1988 and 2011. The study, by Dr. Steven Narod of Women's College Hospital in Toronto, showed that DCIS patients had the same risk of dying of breast cancer — just over 3 percent within 20 years — as women in the general population. In other words, the surgery, radiation and drugs didn't make any difference for the vast majority of patients.

For years you've been telling your friends, family, co-workers and anyone who will listen that you're addicted to cheese. It's a part of every meal or snack, and you think about it constantly. According to a new study from the University of Michigan, cheese crack is a real thing. And so is your addiction.

The study, published in the U.S. National Library of Medicine, examines why certain foods are more addictive than others. Researchers identified addictive foods from about 500 students who completed the Yale Food Addiction Scale, designed to measure if someone has a food addiction.

Pizza, unsurprisingly, came out on top of the most addictive food list. Besides being a basic food group for kids, college students and adults, there's a scientific reason we all love pizza, and it has to do with the cheese.

The study found certain foods are addictive because of the way they are processed. The more processed and fatty the food, the more it was associated with addictive eating behaviors.

In November 2010, when I was 25 years old, I moved in with a man who was 98. This man, whom I'll call Mr Schecter, wasn't a friend or relation or anyone I knew. He was a Holocaust survivor in the first stages of dementia, and I'd been hired to look after him. Although my background was in clinical psychology, I was by no means a professional caregiver. I was employed because Mr Schecter's son – I'll call him Sam – had seriously underestimated his father's condition. Sam's mistake was understandable. The most obvious paradox of dementia is the victim's frequent inability to recognise it, and Mr Schecter went about his life as though burdened by the normal aches and pains of aging rather than by an irrevocable and debilitating illness. If he put the laundry detergent in the oven or forgot which floor he lived on, he'd shake his head and sigh, Mayn kop arbet nisht ("my head doesn't work"). But it was a lament, not a diagnosis. And this denial, both clinical and profoundly human, led Sam to misjudge the illness as well.

Friday, October 23, 2015

My son's first word was ''Mama.'' His second was ''Bamba.'' It is among his favorite things, right up there with picture books, his blanket and the washing machine. The product was born nearly five decades before he was, when its manufacturer, Osem, swapped out the cheese it had been dusting on its corn puffs for peanut butter, a more kosher-friendly alternative. Quickly it became Israel's national snack; now everyone eats Bamba there, from 9-month-olds — like my son — to 90-year-olds. Osem churns out one million bags a day in a country of eight million people. That's what I hear, at least. I've never been. I first learned of Bamba through a study published in February in The New England Journal of Medicine.

One night last summer, around 3 a.m., I was reading on my iPhone while nursing, and I came across a study led by a pediatric allergy specialist named Gideon Lack. He had noticed that Israeli Jews were much less likely to be plagued by peanut allergies than their British counterparts, and he sought an environmental explanation. It didn't take long for him to land at the high chair. Lack and his colleagues designed a longitudinal study, feeding small amounts of Bamba to babies at high risk for developing an allergy (and none to a control group) from the time they began eating finger foods until they turned 5, ulti­mately finding that the snack reduced their risk by 81 percent.

Tuesday, October 20, 2015

Quickly identifying people who have suffered a first schizophrenic episode and treating them with coordinated, sustained services sharply boosts their chances of leading productive lives, according to a major study being published Tuesday. And the treatment can be provided in a typical community mental health setting, the researchers concluded.

The study's findings offer new hope for individuals with the severe mental illness. Although it affects only about 1 percent of the population, far less than depression, schizophrenia and its associated disorders often have a devastating, lifelong effect on individuals and families.

Schizophrenia often consigns people to homelessness, incarceration and unemployment. The hallucinations, delusions and often incoherent speech that mark it have proved notoriously difficult to combat with standard treatments, which for many people include only medication and individual therapy.

"The United States is really a decade behind the rest of the world in doing what we already know works," said Vinod Srihari, an associate professor of psychiatry at the Yale School of Medicine, who was not involved in the study but has conducted similar research. With the new findings, "it's possible now to say that in many community settings . . . it is possible to deliver this kind of coordinated care and the outcomes are good."

The study, called Recovery After an Initial Schizophrenia Episode (RAISE),found that people who are provided years of "coordinated specialty care" in community clinics had a greater quality of life, more involvement in work and school, and less ongoing pa­thol­ogy than others who received typical care.

Monday, October 19, 2015

When anyone proposes reducing prescription drug prices — as Hillary Rodham Clinton and Bernie Sanders recently have — the most commonly heard criticism is that it would squelch innovation. But not all pharmaceutical innovation is valuable. Though some drugs are breakthroughs, some offer only marginal benefits at exorbitant cost.

There is a way to keep prices low while encouraging drug companies to innovate: Look to Europe and elsewhere, where drug prices are a fraction of those in the United States. Germany, Spain, Italy and a half dozen other countries have pushed drug prices lower with a system called reference pricing. It has led to drug price decreases and significant savings in the Canadian province of British Columbia as well as in Germany, Italy, Norway, Spain and Sweden. A study published in the American Journal of Managed Care found that price reductions ranged from 7 percent to 24 percent.

Here's how it works: Drugs are grouped into classes in which all drugs have identical or similar therapeutic effects. For example, all brands of ibuprofen would be in the same class because they contain the same active agent. The class could include other nonsteroidal anti-inflammatory agents like aspirin and naproxen because they are therapeutically similar. The insurer pays only one amount, called the reference price, for any drug in a class. A drug company can set the price of its drug higher, and if a consumer wants that one, he or she pays the difference.

Sunday, October 18, 2015

They found him in the living room, crumpled up on the mottled carpet. The police did. Sniffing a fetid odor, a neighbor had called 911. The apartment was in north-central Queens, in an unassertive building on 79th Street in Jackson Heights.

The apartment belonged to a George Bell. He lived alone. Thus the presumption was that the corpse also belonged to George Bell. It was a plausible supposition, but it remained just that, for the puffy body on the floor was decomposed and unrecognizable. Clearly the man had not died on July 12, the Saturday last year when he was discovered, nor the day before nor the day before that. He had lain there for a while, nothing to announce his departure to the world, while the hyperkinetic city around him hurried on with its business.

Neighbors had last seen him six days earlier, a Sunday. On Thursday, there was a break in his routine. The car he always kept out front and moved from one side of the street to the other to obey parking rules sat on the wrong side. A ticket was wedged beneath the wiper. The woman next door called Mr. Bell. His phone rang and rang.

Then the smell of death and the police and the sobering reason that George Bell did not move his car.

Each year around 50,000 people die in New York, and each year the mortality rate seems to graze a new low, with people living healthier and longer. A great majority of the deceased have relatives and friends who soon learn of their passing and tearfully assemble at their funeral. A reverent death notice appears. Sympathy cards accumulate. When the celebrated die or there is some heart-rending killing of the innocent, the entire city might weep.

A much tinier number die alone in unwatched struggles. No one collects their bodies. No one mourns the conclusion of a life. They are just a name added to the death tables. In the year 2014, George Bell, age 72, was among those names.

As the sun set on a Saturday in early February, Mubarak Angalo, a farmer in Sudan's Nuba Mountains, was riding in a pickup truck with two friends. They had spent the day at a market, selling vegetables, and were returning to their village when they heard a low droning sound overhead. Instinctively, they knew what it was: the engines of a Soviet-built Antonov bomber. The driver came to a stop, leaned from the window, and looked up. Mubarak listened, hoping to hear the sound diminish.

Nuba is a region of mesa flats, scrubby hills, and escarpments near Sudan's southernmost border. In the rainy season, its sorghum fields and flowering neem and baobab trees are brilliant greens, and the canopy hides the earthen paths that people travel on between villages. February is the middle of the dry season, however, when the landscape is a milk-coffee brown and the paths are exposed. Antonov pilots scan the horizon easily, looking for dust clouds kicked up by tires.

Nuba has been a war zone for most of the past 25 years, as the government of Sudan has tried to drive Nubans from their land. President Omar al-Bashir, whose regime is dominated by Arab descendants and Islamists, has declared a jihad against the people of Nuba, blacks who practice native religions and Christianity but also Islam. In the past four years, the holy war has been waged largely from the air. The Antonovs strike homes, schools, churches, crop fields, clinics. They drop cluster bombs that send out shrapnel in all directions, inflicting maximum damage on people and livestock. The bombing this year has been the worst in memory. Saturdays, when Nubans set up village markets, are especially lethal.

Every Nuban knows what to do when the drone of the Antonov engines comes: Parents teach children; schools perform drills. If there is a foxhole nearby—and foxholes are ubiquitous, thanks to the constant bombardment—you get in it. If not, you lie facedown where you are. And if you are in a vehicle, you stop, stay inside, and crouch as low as you can. Under no circumstances do you try to run.

As Mubarak and his friends waited in tense silence, the engines grew louder. Mubarak, in his late twenties, knew the rules but panicked. As the plane flew overhead and then released a bomb from the hatch doors in its belly, he jumped from the truck and began running.

About eight hours later, shortly after midnight, the pickup approached a large compound, and the driver honked the horn. A guard unlocked a chain and opened the gate. The driver pulled into a cool courtyard of raked sand and saplings. This was Mother of Mercy Hospital.

I rushed into the bedroom and watched my wife, Rachel, stumble from the bathroom, doubled over, hugging herself in pain.

"Something's wrong," she gasped.

This scared me. Rachel's not the type to sound the alarm over every pinch or twinge. She cut her finger badly once, when we lived in Iowa City, and joked all the way to Mercy Hospital as the rag wrapped around the wound reddened with her blood. Once, hobbled by a training injury in the days before a marathon, she limped across the finish line anyway.

So when I saw Rachel collapse on our bed, her hands grasping and ungrasping like an infant's, I called the ambulance. I gave the dispatcher our address, then helped my wife to the bathroom to vomit.

I don't know how long it took for the ambulance to reach us that Wednesday morning. Pain and panic have a way of distorting time, ballooning it, then compressing it again. But when we heard the sirens wailing somewhere far away, my whole body flooded with relief.

I didn't know our wait was just beginning.

I buzzed the EMTs into our apartment. We answered their questions: When did the pain start? That morning. Where was it on a scale of one to 10, with 10 being worst?

"Eleven," Rachel croaked.

As we loaded into the ambulance, here's what we didn't know: Rachel had an ovarian cyst, a fairly common thing. But it had grown, undetected, until it was so large that it finally weighed her ovary down, twisting the fallopian tube like you'd wring out a sponge. This is called ovarian torsion, and it creates the kind of organ-failure pain few people experience and live to tell about.

"Ovarian torsion represents a true surgical emergency," says an article in the medical journal Case Reports in Emergency Medicine. "High clinical suspicion is important. … Ramifications include ovarian loss, intra-abdominal infection, sepsis, and even death." The best chance of salvaging a torsed ovary is surgery within eight hours of when the pain starts.

There is nothing like witnessing a loved one in deadly agony. Your muscles swell with the blood they need to fight or run. I felt like I could bend iron, tear nylon, through the 10-minute ambulance ride and as we entered the windowless basement hallways of the hospital.

And there we stopped. The intake line was long—a row of cots stretched down the darkened hall. Someone wheeled a gurney out for Rachel. Shaking, she got herself between the sheets, lay down, and officially became a patient.

MUNSTER, Ind. — On a spring evening last year, Debra Davidson flipped on the television to watch the local news. When an item came on about her longtime physician, she perked up and leaned forward. Then she screamed. Her husband rushed into the living room to see if everything was O.K.

Everything was not O.K. The report said that her cardiologist, Dr. Arvind Gandhi, had been sued by two former patients who accused him of performing unnecessary operations.

Mrs. Davidson had been treated by Dr. Gandhi for more than three decades. She first saw him for an irregular heartbeat when she was 27. For years, she took the medication he prescribed. When Dr. Gandhi said she needed open-heart surgery in 2011, she scheduled it immediately. When he subsequently inserted mesh stents three times to remove blockages from her arteries, she never questioned the procedures.

Only last year did she resist one of Dr. Gandhi's recommendations: to implant a pacemaker. Instead, he inserted a heart monitor under her skin but asked her to reconsider her resistance to a pacemaker.

Mrs. Davidson is now one of 293 patients around Munster, Ind., who have filed lawsuits against Dr. Gandhi and two other doctors in his practice claiming that they performed needless procedures.

The Indiana state Medicaid program has started an investigation, and one doctor not named in the litigation said he had received a subpoena from the United States attorney's office and provided the medical charts of several former patients of Dr. Gandhi and his colleagues that he has since treated. Lawyers for Dr. Gandhi and his practice, Cardiology Associates of Northwest Indiana, said they had not received any subpoenas, and the doctors denied any wrongdoing.

In recent years, federal officials have brought several prominent cases against cardiologists and hospitals, accusing them of performing unnecessary procedures like inserting stents into coronary arteries. While medical professionals say there is no indication that cardiology has more unnecessary procedures than, say, orthopedics, they do note that the specialty has come under increased scrutiny by regulators because the procedures tend to be reimbursed by Medicare and private insurance at significantly higher levels than those in many other specialties.

"Cardiology, whether we like it or not, is generally a big moneymaker for hospitals," said Dr. Steven Nissen, chief of cardiovascular medicine at the Cleveland Clinic and the former president of the American College of Cardiology. "We are still a fee-for-service system, and that creates, in my view, misaligned incentives among some physicians to do more procedures and among some institutions, particularly in areas where there is not tight medical supervision, to turn a blind eye and enjoy the high revenue stream."

Couch features essays by psychotherapists, patients and others about the experience of therapy — psychoanalysis, cognitive behavioral therapy, group therapy, marriage therapy, hypnotherapy or any other kind of curative talk between people behind closed doors.